Camp Registration Form

Full Name

First NameLast Name

Gender

Birth Date

MonthDayYear

You will be at least 18-years-old at the time of CampOUT and will not require parental consent to participate.

Pronoun(s)

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

School and /or group affiliation

T-shirt size

Bunkmate / Cabin request

Dietary restrictions

Accessibility needs

Will you be riding the bus?

Would you be interested in performing or presenting a workshop? If so, what talent or topic would you cover?:

Short essay

Tell us, in your own words, why you'd like to attend and how attending this event will contribute to your activism and involvement in the community.

Parent(s)/Guardian(s) Information

Parent / Guardian Name

First NameLast Name

Primary Number

Area CodePhone Number

Please choose

E-mail

Parent / Guardian Name

First NameLast Name

Primary Number

Area CodePhone Number

Please choose

E-mail

Additional contact information

Emergency Information

Contact Name, if different than above

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the youth have any known allergies to food or medication? If yes, please describe.

Does the youth have any mental or physical health conditions? If yes, please describe.

Does the youth have any special needs (mental, emotional, and/ or physical for which you are requesting accommodation? If yes, please describe.

Is the youth taking prescription or OTC medication(s)? If yes, please list and explain any instructions.

I authorize my child to take their medication(s) without supervision

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Payment

A deposit of $amount is required by date to secure registration. The total cost is $amount, if paid in full by date. $ amount full payment afterwards.

PayPal Payment

USDCampOUT 2017

Scholarship request - choose one:

Name of event

PayPal Payment